Wednesday, September 09, 2009

Latest on Caster Semenya: Results pending as we look at the possibilities and the importance of testosterone

Well, it's been just over a week since my last post - I do apologize for the break, but as I said - "post-Tour and IAAF World Championships burnout!"

It's been a busy time, catching up on some work, and so I have missed a few newsworthy stories, and hopefully in the next while, I'll be able to catch up. Between now and late September, that is, because then the Fall marathon season starts, first with Berlin, then onto Chicago and New York. But for now, we have a bit of "breathing space" to cover some stories and topics in more detail.

Caster Semenya: Latest news from SA

The big story in SA has continued to be that of Caster Semenya. The latest development saw ASA's Performance Manager, Wilfred Daniels, resign as a result of what he felt was mismanagement of the situation, and the fact that ASA lied to Semenya when they began the process of sex testing back in July. Daniels stated that he was unable to look himself in the mirror, and it's a strong stance to take for a man who has been involved in the sport for many years.

That was followed by Semenya appearing in a magazine in South Africa, having received a make-over including makeup and women's clothing sponsored by a few local fashion chains. The story and photo-shoot have caused some controversy again, exposing a split in perceptions. Some say it's great for Semenya, others are more cautious and still others feel the shoot was distasteful. The best piece I read on it was from Owen Slot of the Times, and you can read it here.

The IAAF testing results on the way

And then finally, the test results from the IAAF are ever nearer to being announced. Last night, the local news said "within days", and then this morning, I read this piece from the Telegraph saying that the results may take a week to 10 days.

The Telegraph piece also mentions that the test results are known, but that the IAAF will commission a panel of independent experts to review the results, hence the delay. The reasons for external review? I guess that depends on your point of view. Part of it seems to be that the results are not clear-cut, that they suggest sufficient doubt to warrant further opinion. The other part has been reported as the IAAF wanting to cover itself given the political nature of the matter.

The shadow of doubt: An inconclusive finding is the worst-case scenario

Both seem likely, but if the result is marginal, too close to call, then regardless of what the final verdict is, it leaves a great deal of room for doubt. And doubt is unhealthy for all concerned - it means the benefit of doubt should go to Semenya (quite rightly), but it leaves a lot of scope for future controversy. For Semenya's rivals, many of whom are already highly suspicious if not straight-out convinced of her ineligibility, it means their doubts remain or even grow. For Semenya, doubt means suspicion well into the future, and a very difficult international career, since questions will only remain. And for the IAAF, the entire process of sex verification is undermined (which, admittedly, many will say is a good thing...)

So I believe the key is that things should be clear-cut, conclusive. An inconclusive finding produces no 'winners'. I've done a few presentations on this in the last two weeks - one to the academic department and another for the public through the Sports Science Institute of SA, and it has certainly given me room for thought.

The possible outcomes: What is on the table?

So, in the lead-up to the results being known, I guess the following are the four options:

A conclusive negative finding: This allows Semenya to continue to compete, no problems or questions asked. It is the best result for Semenya, and for SA athletics. I dare say that if this happens, then SA has the next world record holder on their hands, assuming she's managed and coached well (these may be rather big 'ifs' given how management are going about things). I would also dare say that this is no longer an option, since a conclusive negative finding would not require any more delays in announcement. I'd therefore all but rule it out of contention at this stage.

An inconclusive finding: This is the worst-case scenario. It would allow Semenya to continue competing, which is good for her, and should be respected. But it won't be. Competitors will doubt, Semenya will compete under a cloud and it will be very difficult for all concerned, in the longer term. This is the "doubt" scenario I spoke of previously.

If I had to guess (and it is a guess), this is a likely scenario, given how difficult it is to actually prove performance advantages based on biology. It's one thing finding physiological differences, quite another preventing competition. So rightly or wrongly, it means Semenya competes with permanent doubt. Not pleasant for anyone, least of all her rivals (who are silent protagonists in this whole issue)

A conclusive finding of advantage: Whether due to a disorder of sex development that causes an intersex condition, or a medical problem, this scenario means Semenya has to either be treated (if possible) or cannot race against women in the future. Those are tough options for Semenya. With luck, it'll be the former option and she'll be OK to race after treatment. This depends on what condition, if any, is present.

Positive for doping. This has rarely been spoken, but certainly is implied by many articles that have raised the issue that ASA's head coach advisor is Dr Eckart Arbeit, the former East German doctor known for his involvement in doping programmes in the doping-era of athletics. That's not to say he's responsible, or that there is doping, but it remains on the table as possible. That is purely because of the rapid nature of performance improvement, which, taken in isolation, compel one to ask these questions below is a chart showing her progress between July 2008 and August 2009.

Dismissing the possibility altogether would be premature. Having said that, I do think that like option 1, this can be largely ruled out since it would have emerged by now.

The testosterone issue: Males vs females

One of the rumors (I must point out that it is still unconfirmed) is that Semenya's testosterone level was three times that expected of a female athlete. That was reported about a week and a half ago. There are a few problems with this report - the main one is that we don't know what "expected" value they used. There is a range of testosterone values for females, and it's unclear whether the reports are based on the mean, the mode, the median, or the upper limit. Given that doubt, it's pretty meaningless to say "three times higher".

However, in the past few weeks, I've had the opportunity to chat to many endocrinologists, and this testosterone level is actually very important. The IAAF policy states that when it comes to decisions about people competing after changing sex, the crux of the matter is the level of testosterone, and it's likely true of any case. So the level of testosterone is crucially important. That means that the next question is what is typical for males and females?

Below is a chart looking at commonly referred to values for males and females.

It reveals two things:

First, the ranges are wide. That means it's even more important to know what you are comparing a value to. Quite clearly, people are not equal, and so to compress everyone into a narrow band is 'unphysiological'.

Second, and maybe more important, the ranges don't overlap. In fact, they're not even close. The bottom end of the male spectrum is almost 400% higher than the top of the female range. And, importantly, males who lie in the bottom of that range are usually quite ill - they have hypogonadism requiring medical treatment, and the typical male value is much higher than this 9 nmol/L lower limit. The difference between males and females is thus enormous.

Similarly, women do NOT naturally have testosterone levels above the upper end of their range. In fact, my discussions with chemical pathologists and a few endocrinologists have revealed that if a female presents with a testosterone of 4 nmol/L, they are considered to have pathology that requires treatment. Candidates for the conditions causing this level are Congenital Adrenal Hyperplasia (CAH), Androgen Insensitivity Syndrome (AIS), an androgen producing tumor, alpha-5-reductase deficiency, and a host of other DSDs (disorders of sexual development).

The importance of the testosterone level?

This is very important, because it means that the testosterone level would be highly suggestive of something related either to a medical condition or an intersex condition that MAY provide a performance advantage. It's not sufficient to decide on a verdict, however, because in the case of AIS, for example, a person can have high testosterone levels without any performance benefit, since they are insensitive to androgens. The conditions causing elevated testosterone are thus not necessarily performance-enhancing, and so you can't simply use it to decide, that would be oversimplifying an enormously complex problem far more than it should be.

However, testosterone is one of the few variables that doesn't have some overlap between males and females, and that makes testosterone a crucial variable, at least in terms of diagnosis. Things like muscle mass, strength, body fat, height, weight all have considerable overlap, but it's pretty clear that women don't approach male levels of testosterone unless some pathology is in play.

The confidentiality issue

Time will tell what the testing finds. One thing that must be pointed out is that these results may never be known. They are supposed to be confidential. However, given the media frenzy around this case, I find it inconceivable that they will be. Purely scientifically, it would of course be great to know what physiology is in play (just as I'd love to know the physiology of Usain Bolt or any other elite athlete).

However, medical confidentiality should dictate that we never know the details, only the outcome. Somehow I don't see this happening, and there's going to be a lot of rumor, and some truth emerging in the next few weeks. It's inconceivable that it can remain confidential, having come this far already. No doubt there is more to come...

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Comments:

Normally I am used to "scan" articles. But now I've have read every word. Great reading.

On the Track and Field News Forum almost anything related to Track & Field will be discussed, so also Semanya's case. But these topics mostly immediately have either been locked or removed.

But I try to reconstruct my last post, which I subtitled: "Only the facts".

2008 World Youth Champs BydgoszczPre-race best 2:08.00

Semanya is leading through the first lap with halflap splits of 29,43s and 34,09s (63,52s) and then gradually begins to fade quite like Pamelo Jelimo in Berlin. Semanya still tries to come outside but soon "gives it up" and "jogs" to the finish.

Thank you for explaining what the mainstream media seems to ignore: that there is no overlap between men's and women's normal testosterone levels. A medical condition producing too-high levels of testosterone in a female needs to be corrected before she can be allowed to compete as a female.

There has been some speculation that the rash of world records produced by Chinese women distance runners in the 1990s could have been the result of exploiting a population in northeastern China that had congenital anomalies of this nature.

Caster Semenya is not the first elite woman athlete to face this situation.

A great post! A couple of questions come to mind: What are the actual physiological/anatomical/psychological limits set by the IAAF beyond which an athlete can not be classified as "female?" Have these ever been published? Also, why in the world did ASA choose Arbeit to be coach, given his checkered history?

Frans, that's brilliant data, really interesting. An enormous improvement, and the point I've tried to make in my presentations is that it should stimulate suspicion. Not prove anything mind you, but ask questions. Nothing wrong with that. I guess one could say that a young athlete was just maturing and starting training seriously - but a 17 second improvement, that's 14%, that is highly unusual.

To Janet:

THank you, and thank you for pointing out the Chinese women example. I had never heard that. Do you have any additional information on that, because I'd love to look into it a bit more...?

To Owen:

I dont know those limits, because as far as I can tell, they are not published. Only the policy is published, and the policy only makes reference to the "testosterone is the crux of the matter", not any reference points, or limits. I think it's impossible to set a cut-off, but the point I was getting at in the post is that when it comes to testosterone, there may not be a cut-off point, but there is certainly a range in which levels become very suspicious and it seems to me that they can quite safely exclude competition on the basis of this value, plus some other factors (like whether the person has AIS)

As for your Arbeit question, I remember this well. It was 2002, and they first approached him. THe media here got wind of it, and caused such a fuss that ASA were forced to back down and announce that they would not appoint him.

Then a few years later, they appointed him quietly in a position as advisor, slipping it beneath the radar of the media. Over time,his role grew and no one really noticed enough to cause the same fuss as before. So there you go - how to get away with it. Why did they go for him? Who knows? He obviously knows a tremendous amount about the sport, I am sure his knowledge is second-to-few. But you ask a good question...

Finally, to Amy:

Yes, I hope so. The magazine are portraying it very positively, as they would. Who knows what is going on in her mind? There's so much spin and PR in this country right now (not sure where you are), it's impossible to fathom who's thinking what.

Gender, a psycho-social construct popularised by feminist theory, is not the same category as the biological category of sex familiar to any biology student.

It seems evident that Semenya and her family believe that Semenya was born belonging to the female sex, and that Semenya was raised believing herself to be female. Therefore, Semenya's gender is and has been until recently female (although that may change in the future).

Chromosomal, hormonal and other medical tests may indicate that Semenya is biologically more male than female. But the test results will not in themselves change Semenya's gender. With time, of course, her and others' knowledge of the test results may well change that perception.

"Therefore, Semenya's gender WAS and has been until recently female (although that may change in the future)."

By necessity, I'm being deliberately vague when I say "recently". 2002? Last year? From the point of view of the responsibility of the regulatory authorities for such matters, this seems to me to be the crux of the matter.

You're 100% correct. In fact, when this started, my very first post used "gender" and then someone helpfully pointed out that sex was the biological term and since that, I've tried to use "sex verification" whenever I could.

Funny thing is that everyone, including scientific studies on this issue in sport, use gender, which as you point out, is not actually in question.

I guess for completeness' sake, the accurate question is whether Semenya's gender and her sex are congruent. If the biology suggests she is not entirely female, then they have to make a decision based on the biology, and her gender won't factor into it.

Will it change? I don't know. Unless Semenya is shown to be male, I suspect her gender will remain female, if she's an intersex individual, except she may not be able to compete as a female (unless she has treatment, if possible).

Thanks for your reply Ross. Your reply highlights one of the many things that I like so much about this blog - the willingness of both you guys to listen to the feedback from readers and then, if warranted, modify your take on a topic. The net outcome is a blog that is not only extremely informative and scientifically rigorous but also a cauldron for debate - which of course is exactly what a blog ought to be but so often, alas, fails to be.

I want you both to know that this blog is the best I have ever come across on any subject. It knocks most mainstream media sports reporting into a cocked hat. Keep up the great work guys!

Why don't you, the IAAF and the Australian media take a test to determine if you're 100% human or half-human half-animal!!?? This girl is not your little scientific experiment or lab rat! Leave her alone!! People do not always fall neatly into the gender binaries or into any category - why do humans always have to categorise each other so strictly? It's very limiting and sometimes borders on the absurd (this case notwithstanding)! Science is not everything and life is not fair - you can't blame someone for winning the genetic lottery! And denying that Caster's case of being a genetic anomaly like Phelps or Bolt doesn't do you much credit as a so-called 'scientist.' Educated people like to think they know it all, but we are really clueless, and you are at the top of the clueless list! Apparently according to an individual from your university, sex in Caster's case can be so ambiguous that at the end of the day, no one can really know for sure and the experts' verdict will be determined by nothing more than bias!! In this case, even the politics and the incompetent handling of the case might weigh in as the IAAF stands a good chance of isolating itself from some countries in the future! And for the record, I will not be visiting this horrendous site again if this is the type of diarrhoea you are prone to printing!

Caster Semenya has a unique condition of possessing remnants of both male and female genitalia. Intersexuality, as it is known scientifically, is indeed a rarity in 'higher' animals. With this condition, if an individual can not function as both a male and a female reproductively, it is more correctly termed pseudohermaphrodite. The rarest of this pseudohermaphrodite condition is a male pseudohermaphrodite in which an individual appears, phenotypically, female but whose internal genitalia are those representing “maleness.” Caster Semenya appears to be this type. A colleague and I have been studying a unique form of intersexuality on remote islands of the archipelago of Vanuatu in the Southwest Pacific since 1993.( See www.swpacificresearchfoundation.com) On certain isolated islands intersexual pigs are found possessing this condition. On Vanuatu, pigs are woven into the very fabric of traditional life. Male pseudohermaphroditic pigs can be found here in relative abundance and nowhere else in the world. Occasionally intersexes are identified in pig and cow slaughter houses throughout the world. Because these unique pigs are revered by the villagers in Vanuatu that still practice “Kastom”, this condition is purposely bred for, thus perpetuating the condition. A man's value in a Vanuatu village is proportional to how many pigs he owns. These intersexual pigs are worth one hundred “normal” pigs and are, indeed, a valuable commodity. Because of our research, another mammal species with this condition has been identified which will enable us to learn more about this condition in humans. For more information contact; James K. McIntyre Director Southwest Pacific Research Foundation 1009 White Street Fernandina Beach, Fl. 32034 USA jmcint6317@aol.com 904-261-5630

Hopefully you have decided to visit the horrendous site long enough to read more diarrhoea.

To respond to your comment would be to justify it - you need to step back, rope in your emotions and actually read what has been written, because EVERYTHING you write (and I mean everything) has been written on this site over and over again. You have simply not read the site, choosing instead to allow the rush of blood to the head, and the purple haze of irrationality to cloud your judgment.

People who "know everything" are bad, yes, but what is worse is someone who is wilfully ignorant, and so I'd urge you to please read the comments and the posts, all of them, not just one, and then just think before you post, because you are being unfair.

That said, read the comments to this post, and then read yours again, and notice how out of place it is.

After reflecting on my unnecessary outburst on this blog and how it might be received, I would like to apologise profusely (I see I'm too late as a savage counter-attack has already been posted, but I guess I had it coming as my original post was very personal).

The only reason this is so personal for me is because I myself am an androgynous-looking male who has had countless stares and careless whispers behind my back about how I am and I can tell you that it is not fun at all having who you believe yourself to be critically questioned and analysed on a regular basis. Being treated like some sort of alien-being qualifying for scientific prodding and to be 'figured out' is not my idea of humane treatment. But nonetheless, I apologise unconditionally.

(However, I still do not think printing on Caster's alleged results by the media and in the process violating her privacy rights is justified at all - trying to excuse the Daily Telegraph's actions by blaming ASA and the IAAF is just not on. None of us would like to be treated like this girl has been. Civilisation is not about driving a car or using technology, it's about how you treat your fellow man [no pun intended], and the way Caster has been treated and continues to be treated leaves much to be desired).

Welcome back, I'm glad you did come back. Thank you for the balanced reply - I must apologize if my response was 'savage', I was actually trying to unemotively make the point that you did come across as emotional, and maybe made the same error in return! I certainly did not mean to be personal though, but I see quite often that people make the emotional judgment before consideration and that's what it seemed. So apologies both sides!

But thank you for returning and clarifying.

if I may do the same - I'm not condoning or excusing the Daily Telegraph at all. In fact, when the article came out, I pointed out numerous mistakes and assumptions, none of which were warranted, and all of which only contribute to what is becoming a bigger and bigger debacle every day.

I have said a few times that the leaks were wrong - those are what has caused this to be played out in public. Should it be left alone now? I guess in one sense, yes, but in another, no. Certainly I won't be the one to expose any new facts, but I feel that if "facts" or allegations are printed (as by the Telegraph), then where they are wrong, they should be pointed out, which is what I was trying to do.

For example, the term hermaphrodite, the possible action by the IAAF and so forth. If the speculation leads to wrong thinking and more judgment, I think it's helpful to try to provide some balance.

That was in a post after this one, I'm not sure if you've seen it?

In any event, I've often wondered if it should be discussed, but I think it's important, once out in the public, to try to best represent the facts.

My approach to the management side is partly because I'm in SA, and also, I must confess, because I know some things that have yet to be exposed, and which must be brought out - not relating to Semenya, but to how she was treated BEFORE Berlin. I think it's very important.

But I agree 100% with you on the treatment, it's been very poor. I guess my personal issue (and if you have advice, please say) is whether to just leave this alone or whether to try to provide some kind of 'unbiased' (if there is such a thing) discussion of what is being alleged.

On the Daily Telegraph, I agree. It should never have been printed, it should never have been leaked. So point is, I think we agree on a lot of things here, which is what I was getting at in my previous reply!

But thank you again for returning, I really do appreciate it, and hope you'll do so again - your input is valuable and much appreciated!

Jonathan Dugas, PhDCurrent residence:Chicago, USAEmployment: Director of Clinical Development, The Vitality GroupResearch interests: Temperature regulation and exercise performance, with a special emphasis on how fluid ingestion affects those two things. In addition, the effects of exercise on health improvement and risk modification in large populationsSports interests: Cycling, running, triathlon, endurance sports

Full discolusre:The views expressed on this site are not those of the University of Cape Town (UCT), the Sports Science Institute of SA (SSISA), The Vitality Group, or Discovery Holdings.